With world attention focused on a possible US-led war on Iraq, MSF is considering the possible impact that such a war might have on the civilian population of the country. While MSF's intervention in any conflict is primarily reactive and based on evaluation of the actual needs of those affected, we feel compelled to make preparations in the event of a war in Iraq, particularly as we are seriously concerned that access to populations in need of assistance will be problematic and that the conduct of warfare will require increased vigilance on the part of humanitarian organizations. These concerns stem from our experience of attempting to assist the Iraqi population during the last decade on the one hand, and from the US's recent military campaign in Afghanistan on the other.

Despite repeated attempts to evaluate the humanitarian needs and set up aid programs in Iraq, MSF has been unable to establish a presence in the country since the 1991-3 period when we assisted Iraqi Kurds fleeing government repression and provided medical aid in the southern parts of the country following the Gulf War. For MSF, genuine humanitarian aid must reach those most affected by the crisis and be delivered with no political strings attached. Unfortunately, MSF has so far not been successful in obtaining satisfactory guarantees from the Iraqi government that we would be allowed to independently carry out and monitor the delivery of our aid in order to ensure that it benefits those most in need. This is far from the first time that MSF has experienced difficulties working with populations controlled by authoritarian regimes like that in Iraq. In 1998, we withdrew from North Korea, concluding that we were not able to independently assess the needs of the famine-affected population, monitor the delivery of our assistance or evaluate the impact of our nutritional programs.

MSF remains concerned for Iraqi civilians who may be caught in any future military activities in the country. As a possible indicator of things to come, the US-led campaign in Afghanistan this past year has underscored how important it is for victims of conflict that humanitarian actors are granted independent access to them. In Afghanistan, rising tensions following the September 11 terror attacks forced international aid personnel to evacuate the country. Although national Afghan staff played an outstanding role in keeping aid programs running throughout the war, it was difficult to adjust existing assistance programs to the evolving needs. Medical evacuations of war-wounded patients could not be guaranteed, and the provision of assistance to populations freshly displaced by the conflict was undermined. A similar situation could have particularly dire consequences in the event of a conflict in Iraq, where very few humanitarian organizations are currently working.

In addition to limiting assistance efforts, the absence of independent aid workers on the ground in Afghanistan made it difficult, if not impossible, to assess whether all appropriate precautions were taken to limit civilian casualties to a minimum during the conduct of military operations in accordance with international humanitarian law. Instances such as the one in December 2001, when an MSF team helped transport more than 80 dead and 50 wounded civilians to Jalalabad hospital vividly illustrate how devastating aerial bombing can be. Even more so when cluster bombs, an indiscriminate weapon that does not distinguish between soldiers and civilians, are used in populated areas. In the event of a war on Iraq, fears of a possible use of chemical or biological weapons by Saddam Hussein make the situation even more worrisome.

If access to the Iraq population is denied or obstructed during a possible war, how will the required assistance to victims of conflict be provided? How will violations of international humanitarian law be independently reported, with the view that they be halted? For these reasons, all warring parties should guarantee unfettered access for independent aid organizations to impartially assist victims in need.

The military campaign in Afghanistan offers a number of other cautionary messages. During the conflict, neighboring countries such as Pakistan and Iran shut their borders to would-be refugees, essentially trapping fleeing Afghans in the violence they were trying to escape. There are real concerns that the fundamental right of civilians to cross international borders in order to flee violence could also be seriously compromised if war breaks out in Iraq. Already Turkey has closed its borders. During the Afghanistan campaign, the United States did not exert significant pressure on Pakistan to admit fleeing Afghans: will its approach be any different with close allies such as Turkey in the event of a war in Iraq?

During warfare, humanitarian organizations such as Doctors Without Borders seek to ensure that all non-combatants are protected from undue violence and receive requisite assistance for their survival. Restraints on the conduct of war, essentially ensuring a space of humanity during armed conflict, have been a hard-earned, and often threatened, advance in human relations. Western countries played a key role in bringing them about, particularly in the consolidation of international humanitarian law under the Geneva Conventions following WWII.

While it is beyond doubt that repressive regimes such as Saddam Hussein's have committed atrocities against civilian populations, in the event of war, all parties, including the United States and its allies, must respect critical safeguards for non-combatants. Relief operations undertaken by the US military to gain popular support for its war aims, such as air drops of individual food rations during the Afghanistan bombing campaign, and the rebuilding of schools and drilling of wells by Special Forces after the fall of the Taliban, should not distract from its compelling responsibilities to respect fundamental safeguards to which non-combatants are entitled. Commemorating the first anniversary of the September 11 attacks, President Bush defined the protection of civilians as central to the nature of the anti-terror war: "we value every life, our enemies value none, not even the innocent, not even their own." For civilians in Iraq, the test of this promise will be in the actual conduct of warfare and in ensuring the required access for independent humanitarian organizations to provide impartial assistance for those most in need.